APAGS Division Student Representative Network
APAGS-DSRN

DSRN Representative Notification

Dear APAGS:

We have chosen a student in our division who is also an APAGS member to serve as the APAGS-DSRN Representative. The contact information follows:

Student Name: _______________________________________________________
(First, Middle, Last, and Degree)

E-mail: _____________________________________________________________

Telephone: __________________________________________________________
(Area code & number)

Mailing Address:_______________________________________________________
(Street / PO Box)

_____________________________________________________________________
(City, State and Zip Code)

Term of Service: From ______________________ To ________________________
Month/Year Month/Year

Representing Division Number: ___________________________________________

Sent By: ______________________________________________________________
(Name / position)

Referral E-mail: ________________________________________________________

Referral Telephone: _____________________________________________________
(Area code & number)

Please return completed form to APAGS via email.

Or, by U.S. Mail to: APAGS - DSRN
750 First Street, NE
Washington, DC 20002-4242

Or, by Fax to: 202-336-5694

Program Information and Enrollment Instructions
Division Student Involvement Report